Square peg in a round hole: re-thinking our approach to evaluating health system strengthening in low-income and middle-income countries
نویسندگان
چکیده
Borghi J, Chalabi Z. BMJ Glob Health 2017;2:e000406. doi:10.1136/bmjgh-2017-000406 To function effectively, health systems require adequate financing; an effective workforce; reliable information for decision making; good governance; and available medicines and health technologies to deliver quality services to their populations. In low-income and middle-income countries (LMICs), health systems are often limited in this respect and fail to provide comprehensive population coverage of quality healthcare interventions. Health system strengthening comprises strategies to improve one or more of the functions of the health system in order to improve access, coverage, quality or efficiency, and is recognised to be an essential step towards achieving universal coverage goals. Only when health systems function efficiently and effectively can they deliver services to meet population needs. The health system is recognised to be a complex and adaptive web of relationships and interactions between people, institutions and resources, and the need for a complex adaptive systems approach to their evaluation has been recognised by researchers and policy makers. 4 While the application of systems thinking to LMIC health systems is growing, this remains largely descriptive and qualitative in nature. In this paper, we begin by describing the growing importance of donor attention to health systems and resulting aid flows. We argue that current research methods are inadequate to accurately address donor needs: to demonstrate value for money for health systems relative to disease control programmes in a way that recognises and reflects the complexity of the health system and avoids reductionism; and to test system strengthening strategies in the lab, to understand how they work and potential adverse events so as to optimise design. We argue that complexity science methods, and in particular system dynamics modelling (SDM) and agentbased modelling (ABM), offer a promising means of effectively operationalising systems thinking to assess and maximise value for money for health systems programmes in LMICs. In recognition of their importance, aid flows to health systems have been growing. Development assistance to health systems increased from US$ 540 million in 1990 to 2.7 billion in 2015. Global health initiatives opened up funding streams to support health system strengthening in eligible countries Square peg in a round hole: re-thinking our approach to evaluating health system strengthening in low-income and middle-income countries
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